口咽氣管内管留置之重症病人因張口呼吸及無法吞嚥，易造成口臭、口腔潰瘍及分泌物無法清 除，使呼吸器相關肺炎發生率增加。調查發現單位護理人員口腔清潔錯誤率為48.8°%，導因有 四：覺得貝氏刷牙法費時，不知是否清乾淨；書面的標準作業流程沒有「口腔潤濕」此項；白 班和小夜班無規定要口腔清潔；不清楚口腔清潔到底有哪些項目。專案目的為降低口腔清潔錯 誤率至20%。解決辦法為：修定口腔照護標準作業流程、使用牙菌斑檢測劑及口腔凝膠、設定 提醒機制、拍攝正確口腔清潔影片進行在職教育等四項。改善後口腔清潔錯誤率由48.8%降低 至13.9°%，口腔牙菌斑第三級的佔率從76.7°%降為3.3°%，專案執行後可有效改善口腔清潔錯誤 率。

Secretions contaminated with oral, nasal, and gastric bacteria accumulate in the subglottic space, above the endotracheal tube cuff. If these secretions are aspirated into lower airways, the intubated patient will be susceptible to ventilator-associated pneumonia (VAP). Upon investigation, we find that the error rate is up to 48.8%. The possible reasons for the errors are the following: Bayesian brushing method is wasting time, lack of standard operating procedures, day and evening shift staffs procedures and regulations were insufficient, lack of knowledge about oral care of staff. This project was designed to reduce oral care error rate in the surgical intensive care unit (ICU) to 20%. Intervention measures included: (1) establishing standard operating procedures, (2) introducing plaque grading system, (3) increasing display of oral care rhyming verse, (4) providing in-service education on oral care. After the enforcement of the measures above, the error rate of oral care was reduced from 48.8% to 13.9%.grade III dental plaques was reduced from 76.7% to 3.3%, Results demonstrate the effectiveness of using the proposed methods to reduce oral care error rate.